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Seven reasons that 'zero tolerance' doesn't work

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Mention on social media that you have had an unpleasant experience with an abusive patient and I can guarantee that other GPs will rally round offering much needed comfort. You are also likely to hear the term ‘zero tolerance’ and be given the seemingly sound advice that you should not put up with any form of abuse and the offending patient should be struck from your list without a second thought.

I like to see GPs looking out for each other, but these online conversations leave me deeply troubled. My efforts to offer a contrary view have not gone down well.

While I share the belief that we should take any form of abuse in the NHS very seriously, I have major reservations about zero tolerance. In my view it is a blunt, ineffective instrument that makes us more vulnerable, not less, and strikes at the heart of what it means to be a GP.

I know many hard-working caring GPs will disagree with me, and the NHS gives its staff the right to practise zero tolerance should they wish.

And you can accuse me of being an idealist – I am incurable in that regard and fully intend to stay one - but please don’t call me naive. After 23 years in the ‘doctoring’ business, I have sufficient grey hair to refuse to accept that label.

There are seven main reasons I’m so against zero tolerance:

1 Zero tolerance means ducking your responsibility. Getting rid of all your badly behaved patients simply passes the problem on to neighbouring practices. We all have patients who kick off at times and we all need to take our fair share of the load. Refer them to the Violent Patient Scheme? For the violent patients, yes, but for every patient who screams and shouts? They just wouldn’t accept them, and it isn’t a practical solution in most cases.

2 Punitive measures are a poor way to bring about change. Throwing a patient off your list is not an effective way to bring about behavioural change. Quite the opposite, it is likely to enforce the belief that doctors are part of an establishment to fight rather than a support to value.

3 Opposing zero tolerance does not mean condoning bad behaviour. Abusive behaviour is serious whether it is physical or not and should be properly challenged. However, it is possible to care for someone without condoning their behaviour, and to stand firm against abuse without the knee-jerk reaction of throwing someone off your list.

4 Zero tolerance means refusing to listen. Showing a willingness to listen is often the best way to calm someone down. Once someone has been listened to, they often apologise spontaneously and you can challenge them to behave differently next time. It should be about helping someone to want to work with you, because they know you are on their side rather than doling out punitive threats.

5 Zero tolerance contradicts the unique spirit of general practice. What makes general practice truly remarkable is that we never discharge our patients. We never say ‘that’s not our specialty’, or ‘you’re too old’. We don’t judge and we carry on caring for our patients whether or not they listen to our advice or even whether we like them. Where else can people get that level of support? It’s why our patients are so doggedly loyal, despite the best efforts of the government and the Daily Mail. Throwing a patient off your list is the antithesis of this spirit, and should only be used as a last resort.

6 Restoring a good relationship with a difficult patient is rewarding. We teach our registrars how to handle an angry patient, why should we be reluctant to do it ourselves? GPs are some of the best communicators in the country. It takes a bit of time, but the investment is worth it in the end, results in fewer complaints and may just help us sleep better at night.

7 You don’t need zero tolerance to protect healthcare workers from violence. You don’t need tolerance to be set at zero to know that staff safety is paramount. If staff feel physically threatened by a patient, call the police; if there is a danger it will happen again, remove them from your list by all means.

However, at the other end of the spectrum, for patients who will never be violent but who have been verbally abusive, is zero tolerance really our only response?

Dr Martin Brunet is a GP in Guildford and programme director of the Guildford GPVTS. You can tweet him @DocMartin68.

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Readers' comments (57)

  • I completely disagree with this writer. He makes two
    assumptions
    1) That poorly behaving patients should not be treated the same way as they have treated the medical professionals ( strict measures to guarantee they don't repeat the offense).

    2) That there are alternatives to patients who treat health staff appalling

    As a GP who has had to stay quiet on numerous times , while being verbally and racially abuse I say no more!

    It's this kind of thinking that as allowed patients to abuse doctors / clinicians.

    If a doctor abuses his relationship with a patient - he gets suspended or erased from the medical register.
    If a patient does the same, he/she is molly cuddled.

    This has to stop. Enough is enough. For too long we have been shouted at by patients making inappropriate requests and demanding things they know the health service is not meant or designed to provide. When they don't get this- they become aggressive. Doctors are constantly asked to apologise if there is a misunderstanding. Not so patient.

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  • Vinci Ho asks why I wanted to write this article in the first place. It's a good question.

    It's because there is a growing assumption out there that the only strong, self-respecting response to abuse is to fight back with zero tolerance and I think this needs to be challenged.

    I am absolutely NOT saying that we should be doormats, or accept abuse (and thank you Shaba for pointing this out and I agree with your comment entirely that abusive behaviour should be met with consequences). Nor am I saying that we do not have a right to work without being abused - of course we do. However, whether or not I have a right to avoid abuse, stuff happens anyway - and when it does happen, I am more interested in outcomes than rights.

    What I AM saying is that Zero Tolerance is a closed mindset that does not allow for more imaginative solutions. If, by asserting my right to avoid abuse, I remove someone from my list and they go on to abuse a neighbouring GP then that is a poor outcome. If I confront the abuse in-house, deal with it so that there is behavioural change and the abuse stops happening, that has to be a better outcome. It's not soft, it's not cowardly and it requires a great deal of self respect to do it well.

    Of course it is difficult, and sometimes we won't be able to bring about behavioural change, so the option to remove someone always has to be there, but it needn't be our first reaction.

    This is an interesting and, in my view, very important debate. I'm grateful for the constructive comments - both those that were sympathetic to my point of view and those who disagree with me. As for some of the other comments, I wonder if the authors noted the irony that in arguing for a zero tolerance attitude towards any form of abuse they were being...well if not quite abusive then certainly more than a little rude.

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  • Vinci Ho

    I like to add :
    Clearly while politicians from various government have allowed consumerism of health to grow without checks , the presumption that the customer , hence patient , is always right, has already eroded the traditional doctor-patient relationship we have been believing in. This is fortified by our regulatory organisations( to which we pay for their existences) over-regulating our practising with a principle of presumed guilty until proven , if the customers are simply not happy or angry. (GMC answer was emotional resilience training for us!)
    Of course, our lack of resources(time, funding and manpower) will also make it difficult to satisfy some of these 'customers' .
    My worry is this atmosphere has already developed into a culture of polarisation (another one) between us and our patients and we need some revolutionary answers .......

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  • Anonymous | 14 May 2015 0:21am

    Me thinks 705 and 731pm aren't gp's.....probably patients who have been rude!!! Should be 0 tolerance to trolls....

    haha, thats the first time Ive been called a troll! I am not a GP but I work in general practice every working day in psychology services. The GP's I work with are very pragmatic when dealing with difficult behaviour and do this in a multi-displinary way. Dr Brunet is not saying accept abuse, he is saying there are ways to manage it. If you don't want comments from other professionals on this site then change your membership rules. IMO it helps to have my colleagues perspectives in order to reflect and to help my professional development.
    Best Wishes
    Troll/rude patient (not!)

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  • Dear Anon 2.02pm. I assume you are a GP and that you are in favour of zero tolerance.

    I wonder what you would think if one of your patients wrote on a facebook group page that they recommended people stayed well clear of your practice solely on the basis of something you have written? A zero tolerance approach would be to remove them from your list for defamation.

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  • We had a patient that had been thrown out of all the GP surgeries in our town.

    We kept him longer than most but eventually his abuses were intolerable. I understand he now has to go to a neighbouring town for his medical care under a special scheme.

    This is what he deserved. Perhaps he will learn something.

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  • Dr Brunet I suggest you read up on 'enabling' , maybe add it your CPD, you than should change your approach with your VTS. There you go, some +ve feedback.

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  • I would of course, recommend that all GP employers follow zero tolerance. If a patient is verbally abusive to a member of your staff, and you ignore it as is being effectively suggested in this article, you run the risk of that staff member sueing your for constructive dismissal. Most of us run businesses. I don't want abusive customers, they can go elsewhere. If another practice is stupid enough to put up with the abuse and run the risk of damaging their own staff wellbeing, that is their problem. Or just send them all to register with Dr Brunet,

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  • There is a wider aspect to this approach. The NHS has one of the highest stress related illness rates of any major employer in the UK. Many of these people are off after being on the receiving end of abuse that was ineffectually dealt with by line managers toeing the 'the customer is always right' ineffective handling of the situation, Dr Brunet seems to feel that all patient with capacity who are abusive should retain a right to access to health care. I fundamentally disagree and the sooner the NHS 'strikes off' abusers for 12 months so they have to fund healthcare themselves, or go without, the better. I do not care in the slightest what happens to them, and if some suffered as a result, it would rapidly encourage others to think twice about being Abusive, why should staff become ill, and some even take their own lives, to allow this patronising drivel that we must somehow 'understand the needs of the abuser'? Let them rot for all I care,

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